Lower limb ulcers Flashcards
What are ulcers?
abnormal breaks in the skin or mucous membrane
What is the origin of most ulcers?
Venous origin
Other than venous origin, what are the other causes of ulcers?
Arterial insufficiency or diabetic related neuropathy and rarely infection, trauma, vasculitis or malignancy
if there is prolonged or excessive pressure a over a bony prominence what can this cause?
Pressure ulcers leading to skin breakdown and necrosis
How can pressure ulcers be managed?
adequate mattresses to aid repositioning and good wound management
How do venous ulcers appear?
shallow with irregular borders and a granulating base
Where do venous ulcers usually arise?
Media malleolus
What are venous leg ulcers prone to?
infection and then cellulitis
What is the pathophysiology of venous ulcers?
valvular incompetence or venous outflow obstruction which leads to impaired venous return, venous hypertension causes trapping of the white blood cells in the capillaries and fibrin cuff forms hindering oxygenation, white blood cell become activated, release inflammatory mediators to resultant tissue leading to tissue injury, poor healing and necrosis
What are the risk factors of venous ulcers?
increasing age, venous incompetence e.g. varicose veins, pregnancy, obesity, physical inactivity, leg injury or trauma
What are the symptoms of venous ulcers?
painful, usually in the gaiter region of the legs, aching, itching bursting sensation
What will venous ulcers look like?
leg oedema, venous insufficiency such as varicose veins, eczema, thrombophebitis, haemosiderin skin staining, lipodermatoscerlosis, atrophie blanche
How are venous ulcers diagnosed?
clinically but can be confirmed by duplex ultrasound
What junctions fo venous insufficiency usually occur?
Sapheno-femoral or sapheno-popliteal junctions
What does ABPI stand for?
The ankle brachial pressure index
What does the ABPI do?
assess for any arterial component to the ulcers and determine whether compression therapy will be suitable
If there is a suspected infection of the venous ulcer, how would this be confirmed?
microbiology swabs and swab cultures
What is the management for venous ulcers?
leg elevation, increased exercise, (promote calf muscle pump action and increases venous return), lose weight and improve nutrition, multicomponent compression bandaging, also treat any varicose veins
What is an arterial ulcer?
An ulcer caused by a reduction in arterial blood flow, causing decreased perfusion of the tissues and subsequent poor healing
How do arterial ulcers usually form as?
Small deep lesions with well defined borders and a necrotic base
Where do arterial ulcers usually form?
distally at sites of trauma and in pressure areas
What are the risk factors for arterial ulcers?
peripheral arterial disease, smoking, diabetes mellitus, hypertension, hyperlipidaemia, increasing age, positive family history, obesity and physical inactivity
What are the clinical features of arterial ulcers?
intermittent claudication (pain when walking) or critical limb ischaemia (pain at night) previously, painful ulcers that develop over a long time with little to no healing, cold lumps, thickened nails, necrotic toes and hair loss, reduced or absent pulses, if only arterial then sensation should be present
What are the investigations for arterial ulcers?
Ankle brachial pressure index measurement which can then quantify the extent of any peripheral disease , duplex ultrasound, CT angiogram and MRA
What is the management for arterial ulcers?
vascular review, lifestyle changes like smoking, weightless, exercise, statin therapy, anti platelets, blood pressure and glucose, angioplasty with or without spending and bypass grafting, skin reconstruction with grafts
What are neuropathic ulcers?
ulcers that occur due to peripheral neuropathy, where there is a loss of protective sensation leading to repetitive stress ad unnoticed injuries forming, causing painless overs forming on the pressure points on the limb, vascular disease will contribute tot their formation and reducing healing potential
What are the risk factors for neuropathic ulcers?
Diabetes mellitus and B12 defieciency, foot deformity or peripheral vascular disease
What are the symptoms of neuropathic ulcers?
history of peripheral neuropathy, symptoms or peripheral vascular disease, burning and tingling in the legs (painful neropathy), single nerve involvement (mono neuritis multiplex such as CN III or median nerve), amotropic neuropathy (painful wasting of proximal quadriceps)
What would be present on examination of neuropathic ulcers?
variable in size and depth with punched out appearance, there may be a peripheral neuropathy (glove and stocking distribution) warm feet and good pulses
What investigations would be done for someone with neuropathic ulcers?
blood glucose levels, and B12 levels, ABPI and duplex, infection by swabs, X-ray to assess for osteomyelitis, asses peripheral neuropathy with 10g monofilament or ipswich test and vibration with 128Hz tuning fork
What is the management for neuropathic ulcers?
diabetic foot clinic, diabetic control with HbA1c <7%, improved diet and increased exercise, cardiovascular risk managed and regular chiropody, antibiotics, surgical debridement if ischaemic or necrotic, may need amputation
What is Charcots foot?
Neuroaarthropathy whereby loss of joint sensation resulting in continual unnoticed trauma and deformity, this predisposes the patient to neuropathic ulcer formation, there is swelling, distortion, pain, loss of function, rocker-bottom sole, may need off-loading abnormal weight to immobilisation
what score of ABPI, bandaging be applied to a venous ulcer?
over 0.6
